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fit Of C41ifornia-47ealth and Welfare Agency See Instructions on Back nt Paye 6 Department of Health se^'ic•s <br /> mn proved OMB No.2050--0039(Expires 9-30-9 t) Tox!c SubstancesM <br /> Dorol Division <br /> asci riot or type. (Form deapsed for use M floe h: 1 typewriter). and Front 01 Paye Sacramento.California <br /> UNIFORM HAZARDOUS 1 US EPA ID 140. Mamtest 2 Page 1 Mlo mat 0n n IM <br /> WASTE MANIFEST Nadel areas <br /> Document No <br /> 4 5 9 6 a 1.ria required er Fedora Lw <br /> 3 Dua.f or.Name and Mailing Address A. State WHIM Doas ietl Member <br /> Nor Cal Beverage 89745060 <br /> 1800 "E" Fremont Street Stockton, CA 95205 a State Gsntraloes0 <br /> a. Generatora"me(2091 94 3-0 381 <br /> a 5 Transporter t Company Neme B US EPA ID Number C State Transpor ar's to <br /> Php1a <br /> Placer Tractor Service ^ Al D Trans <br /> °Ort <br /> 7 Transporter 2 Company Name BUS EPA ID Number E aside TransportM D 6 <br /> m F Trenaporter's Phone <br /> Evergreen Environmental <br /> — 9 Designated Facility Name and Site Address 10. US EPA ID Number G. State Faciiby's ID <br /> �a! Evergreen Environemtal <br /> Oc 6880 Smith Avenue H. Fatlwys Pnana <br /> _)z k Newark . <br /> 712. Conte more <br /> 13. Total 14. I. <br /> o11. US DOT Description(Including Proper Shipping Name.Hazard Class.and ID Number) Quantity Unh Waste No. <br /> �J No. Type WI/Vol <br /> �p 91tle <br /> 221 <br /> 7z G Fuel petroleum oils-Nos, Combustable Liquids [fEPA/Other <br /> Jrl H NA1270 C I T T NDDITa_._._ <br /> 3 E b. guar <br /> lV R <br /> A <br /> m T EPA/Other <br /> v O <br /> f R c State <br /> 0EPAIOlhw <br /> W d. State <br /> H <br /> 2 <br /> w <br /> U EPA/Oalw <br /> w <br /> W J. Additional Deeaiptione for Materiels Listed Above K. IYrMlin9 Godes for Wastes Listed Above <br /> Z •. . <br /> O b <br /> o, 1-1 VFuel oil with undetermined amount of halogens <br /> w, <br /> al 1-2 Waste Water ° e_ <br /> Z <br /> 0 <br /> F 15. Spatial Handling Instructions and Additional Information <br /> G <br /> 2, <br /> LAI Wear Gloves <br /> J <br /> J <br /> U <br /> Ib <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fuly and accurately described above by proper shipping name <br /> J and are classified,pecked,marked,and labeled,and are in all respects in proper condition for transport by hlghwey according to applicable International end <br /> Nnational government regulations. <br /> Q 111 am a large quantity generator,1 tartly that I have a program in piece to reduce the volume and loaicity of waste generated 10 the dpres I Mn determined <br /> O to be economically practicable a"that!have eelMed the procticab!e method Of ireelmenl grape,or disposal currently available to me which miimizea the <br /> present and future threat to human health and the letwonment.OR,a 1 am a.mall qusOtiy neralor.1 have made a good faith eMpt to minimize my waste <br /> U generation and select the beat waste management method that is available to me and that 1 n afford <br /> Z <br /> WPrinted/Typ Name Signature Month Day pyear <br /> IX <br /> w �Q/ UNSOM <br /> W TR 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> Z A Prialsd/Typed ems slurs Marin Day Year <br /> N <br /> a , m S Ca aqn <br /> g, OP18. Transporter 2 Acknowledgement of Receipt of Materials <br /> Ut Printed/Typed—Name Si re Month Day Year <br /> E u Y <br /> 2 <br /> 19. Discrepardy Indication Space oy-s? LTE.t!A/ /✓ T'S �: _,C�,�fiesl ENL/y�pLfMbNTAL- $E.e✓zGE <br /> A 30 boy io- c��� �5�� � 4 <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials cc by this manifest except as noted in hem 19. <br /> T <br /> y /T ped a Month Day Year <br /> U1C� Q <br /> DHS 8022 A(1/801) Do N Write IoW This L <br /> EPA 8700-22 <br /> (Rev.988)Previous editions are obsolete. White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> To: P.O. Box 3000, Sacramento, CA 95812 <br />